The NFL Head, Neck and Spine Committee—a board of independent and NFL-affiliated physicians and scientists, including advisors for the NFL Players Association—developed the NFL Game Day Concussion Diagnosis and Management Protocol in 2011.
The Concussion Protocol is reviewed each year to ensure players are receiving care that reflects the most up-to-date medical consensus on the identification, diagnosis, and treatment of concussions.
Concussion Game Day Checklist
When a player receives an impact to the head, the player goes into the Concussion Protocol if:
- the player exhibits or reports symptoms or signs suggestive of a concussion or stinger (a nerve pinch injury); or,
- the team Athletic Trainer, booth ATC spotter, team Physician, NFL game official, coach, teammate, sideline Unaffiliated Neurotrauma Consultant (UNC) or booth UNC initiates the protocol.
Then the player must be immediately removed to the sideline or stabilized on the field to undergo the concussion assessment, outlined in the checklist below:
Improvements to the Concussion Protocol
For the 2018 season, the Head, Neck and Spine Committee made additional improvements to the Concussion Protocol:
- Added a third UNC who will monitor the broadcast video and audio feeds of each game from the spotters' booth, and notify on-field UNCs of possible head, neck or spine injuries.
- Defined impact seizure and fencing responses as independent signs of potential loss of consciousness, representing "No-Go" criteria under the current Protocol. Players who display either of these signs at any time shall be removed from play and may not return to the game.
- Required an evaluation for all players demonstrating gross motor instability (e.g., stumbling or falling to the ground when trying to stand) to determine the cause of the instability. If the team physician, in consultation with the sideline UNC, determines the instability to be neurologically caused, the player is designated a "No-Go" and may not return to play.
- Officials, teammates, and coaching staffs have been instructed to take an injured player directly to a member of the medical team for appropriate evaluation, including a concussion assessment, if warranted.
- Required all players who undergo any concussion evaluation on game day to have a follow-up evaluation conducted the following day by a member of the medical staff.
Every NFL player diagnosed with a concussion must follow a five-step process before being cleared to fully practice or participate in an NFL game. This process, developed from internationally accepted guidelines, ensures that each player receives consistent treatment.
Each player and each concussion is unique, and there is no set time-frame for return to participation. Team medical staff consider the player's current concussive injury, as well as past exposures and medical history, family history and future risk in managing a player's care.
After a player has progressed through the five-step process, and is cleared for full participation by his club physician, he must be seen and separately cleared by an Independent Neurological Consultant (INC), jointly approved by the NFL and NFLPA, who is not affiliated with any NFL club. Until cleared by this independent physician, a player may not return to contact practice or play in an NFL game.
Training, Collaboration and Standardized Care
Sideline medical professionals meet over the summer to review the latest protocols and train for the upcoming season. In 2018, the NFL is holding three medical trainings in Los Angeles, New Orleans and Chicago, and the league has expanded the number of attendees to include all Team Physicians, Athletic Trainers, booth ATC spotters, Unaffiliated Neurotrauma Consultants (UNC), Independent Neurological Consultants (INC) and neuropsychologists.
These trainings are "an opportunity for us to learn, to discuss together, to figure out how we can improve our communication and our collaboration," said Dr. Allen Sills, the NFL Chief Medical Officer and a practicing neurosurgeon. "The spirit is really how can we leverage our skills and our experience as a group, to improve player health and safety for our 32 clubs."
Robb Rehberg is a booth ATC spotter who works home games for the New York Jets. "Gathering all the people responsible for the health and safety of players in one place means we can talk about our specific roles, he said. "We can talk about how our roles are supposed to interface, and make sure there's no miscommunication."
Dr. Javier Cardenas is an Unaffiliated Neurotrauma Consultant for the Arizona Cardinals and member of the NFL Head, Neck and Spine Committee.
At the medical trainings, "we get to see our [Head, Neck and Spine] Committee work translated from protocols into implementation," Cardenas said. "In medicine, we know that the more you standardize a protocol, the better off the patient population is, because you eliminate a lot of the variability."
James Collins is the Head Athletic Trainer for the Los Angeles Chargers and President of the Professional Football Athletic Trainers Society (PFATS).
"On game day, it's all about everybody being on the same page," he said, "just like players and coaches are on the same page because they practice. We do the same thing."
"The player's health and safety is the most important thing, and we're educating each other in sessions like this so that we can give the player the best care possible," he said.